Comparative effectiveness of sleeve gastrectomy and semaglutide for weight loss and metabolic outcomes: a prospective non-randomized study.

BACKGROUND: Bariatric surgery and pharmacotherapy represent two major strategies for the treatment of obesity. Sleeve gastrectomy (SG) is the most widely performed surgical procedure and is supported by long-term evidence, while semaglutide, a glucagon-like peptide-1 receptor agonist (GLP-1 RA), has recently emerged as an effective medical therapy. However, prospective real-world studies directly comparing these interventions are limited. METHODS: We conducted a prospective, non-randomized trial at a single tertiary center (ChiCTR2300070632). Adults with obesity were allocated to SG (n = 36) or once-weekly semaglutide (n = 35) based on shared decision-making. Semaglutide was administered for a planned duration of 24 weeks, after which continuation or discontinuation was determined by patient preference. Primary outcomes were percentage total weight loss (%TWL) and changes in body mass index (BMI) at 1, 3, 6, and 12 months. Secondary outcomes included changes in metabolic parameters. RESULTS: SG achieved significantly greater weight loss at all time points. At 12 months, mean %TWL was 28.6% for SG versus 11.3% for semaglutide (p < 0.001). Mean BMI decreased from 32.7 ± 2.8 to 23.8 ± 2.6 kg/min the SG group and from 32.0 ± 2.6 to 28.4 ± 4.0 kg/min the semaglutide group (p < 0.001). Both groups demonstrated metabolic improvements, but SG was associated with greater reductions in triglycerides and greater increases in high-density lipoprotein cholesterol (HDL-C). Among patients who discontinued semaglutide after 6 months (n = 25), mean weight increased from 74.6 ± 11.3 to 83.2 ± 12.3 kg by 12 months, with 32% regaining to baseline weight or higher. CONCLUSIONS: SG achieved greater weight loss and improvements in triglycerides and HDL-C compared with semaglutide. Semaglutide was effective during treatment, but many patients experienced weight regain after discontinuation. TRIAL REGISTRATION: Trial Registry No. ChiCTR2300070632 (2023 April 19).